American Psychological Association

108th Convention
Washington DC, August 4-8, 2000

Photo by Fenichel: Aaron Beck, Albert Ellis

3309 New Concepts in Practice: On Therapy-- A Dialogue with Aaron T. Beck and Albert Ellis

Now here was a historic dialogue between two legends in the field of cognitive therapy. Below is the report which was filed "asynchronously live" from the APA's Convention 2000, to theCurrentTopicslist-serv.

ASYNCHRONOUSLY LIVE FROM APA 2000

Here are a few highlights from Sunday's APA offerings at the Y2k Convention here in Washington. (8-6-2000)
This is a bit lengthy and a bit technical, oriented primarily towards mental health professionals and/or graduate students.....

Two great events on Sunday really illuminated some aspects of personality theory and cognitive therapy for depression and anxiety.In the morning, Aaron Beck, perhaps the "father of cognitive therapy", gave a talk on "Cognitive Therapy at the Cutting Edge", and in the afternoon he was joined for debate and discussion by fellow pioneer Albert Ellis of RET/REBT fame (Rational-emotive-behavior therapy).

Dr. Beck (an MD, who actually calls himself "Tim"),
described how when he started out doing research into personality theory, and psychotherapy, there was no time limit on treatment (i.e, no Managed Care), and one could work as long as necessary until landing "flashes of lightening and insights and synergy". Until one day he realized that most of the insights were his own, and that the most important changes in beliefs had to come from the patient.
Years later, there is a large body of empirical evidence supporting his theory of cognitive behavior, which essentially says that the cause of dysfunctional behavior is dysfunctional thinking, and that thinking processes are shaped by underlying *beliefs*. Situations are interpreted according to basic beliefs and acted on accordingly. "If beliefs do not change," he said, "there is no improvement. If beliefs change, symptoms change. Beliefs function as little operational units". He is very excited about new studies which demonstrate the effectiveness of persuading patients to abandon self-destructive beliefs which serve to maintain dependent and avoidant behavior in particular, even among what are typically seen as very difficult disorders.

Lately Beck (who is famous for his work in treating depression) has been focusing on Borderline Personality disorder, and learning how these patients are dealing (via splitting, presumably), with "numerous dysfunctional beliefs", which "don't get activated until they're in the relevant zone... like a combat zone triggered by a fear of death". He is also seeing success with schizophrenia, where gentle persuasion has been found to successfully help patients acknowledge that hallucinations come from within and can be challenged and displaced. He believes it is "not the hallucinations causing the distress, but the attached beliefs, such as 'I have to do what the voices say or something terrible will happen to me. The voices are omnipotent.'" Beck teaches his patients to control their beliefs, essentially, as does Ellis. He identifies the underlying fears as well, and how they lead to the beliefs. (Someone asked if the schizophrenics are on medication and he said that whatever their treatment was remains in effect but that his treatment is in addition, in these studies.)

I know the above may be very technical for some, and very simplistic for others, but hopefully many will catch some of the flavor, and see the essence of what he's distilled into a few basic concepts over decades of successful study and practice.

ALBERT ELLIS joined Beck in the afternoon, and moderator Frank Farley began by asking the two what the difference is between their theories. Ellis joked that people love to steal his ideas, and after the two of them noted some slight differences, it became clear that they basically are very close to each other's beliefs about beliefs, and differ mostly in technique and style, more than in perspective.

Ellis: "I would like x, but I hate y... versus, I would *like* x, and if y happens, Sh--! But I'll live with it!".
He described his active technique of confronting irrational beliefs by explaining that "Whenever we get people to change their Musts, Shoulds, and Have-to's... they're cooked!" (ie., irrational beliefs will yield to better functioning after being argued out of existence).

Beck said that in his case "we believe that underneath the must is some type of fear or regret. They *believe* they are going to die and they must do something. The depressive patient has an underlying regret: 'I've had a terrible life and I am worthless; therefore I must kill myself and self-destruct.'" Ellis agreed with what Karen Horney called (in one of my own favorite papers), "The Tyranny of the Shoulds".

Asked "what's new" in their thinking about irrational beliefs and their treatment, Beck said he is very excited about the work being done in Europe with schizophrenics, who despite having a supposedly pure-organic symptomology, are responding positively to CT treatment. With this population in particular, he urges careful, supportive challenging of dysfunctional beliefs. Ellis added that it is also important to encourage patients to realize that if one believes something rational, a positive consequence may follow. Ellis re-iterated his earliest theory of ABC (Adversity as defined by the patient, Beliefs, which can be disputed by logical argument, and Consequences of the emotionally charged "hot cognition").

Ellis conceded that things aren't always straightforward or easy, and that a pragmatic approach is necessary: "Does this approach work at this time with this client under which conditions?"

Dr. Farley asked if there are any patients *not* likely to benefit. Beck mentioned psychotics, and some other anti-social disorders. He is becoming more and more convinced that much is possible however, citing how his son Daniel is getting good results with the "mentally disadvantaged". Ellis agreed that it is difficult to work with "physiological disorders" but in terms of other difficult personality disorders, said that he believes fully "30% of these are just people with fears... including several former Presidents."

Ellis reiterated his 3 basic tenets:

People don't just get disturbed by events, but by the *perception*. A+B.

No matter when you developed your belief, you still believe it.

There is no way but work and practice the rest of your damn life!

Dr. Farley asked about the impact of drugs, and Ellis spoke about the predisposition of the brain, but re-iterated how medications are "a mixed bag" and the most important thing in REBT is simply "work, work, work....". Beck commented that medication decisions sometimes boil down to an evaluation of "a practical approach" versus an "ideal approach". Sometimes drugs are already prescribed when patients present, and they don't make a change. It seems as if with some patients, notably panic attack, the therapy works better without drugs. The important thing is that "They need to learn they're not in danger of imminent death". Ellis agreed and said often these attacks are in fact "panic about panic-- get them over that, they improve. 'Sh--, it's too damn bad you panic, but you don't die from it!' Get them over the panic about panic, you may find the panic disappears."

Dr. Farley noted that as we entered the 21st century, many lists came out of the 100 most admired people of the 20th century and Freud was often among them. Any value now, of Freud?

Beck said that he'd spent much of his career as a psychoanalyst and still thinks of himself as "a closet psychoanalyst." He commented that some aspects of Freud's theories, notably psychological determinism, "still influence my ideas today. Ideas produce behaviors and have impact on biological functioning, and further consequences."
Ellis, who last year quipped that Freud wasn't "sexy enough" for his taste, stated simply that "Freud was unquestionably a genius. One of the main things he did was point out the importance--not the sacredness--of the unconscious. It wasn't original [because] Hartmann in the 1860's wrote about the importance of the unconscious, but Freud ran it into the ground! A real obsessional. I think *all* psychotherapists use some elements of unconscious thinking..."

Beck added that speaking of OCD, research has demonstrated how changes occur in the brain following CT. Ellis said "I agree. I practically only treated OCD for 20 years with REBT. Then they discovered Afranil, and I use that too. They improve *if* they work their asses off."

As time ran out, the audience was given a chance to ask a few questions. "What about core beliefs?", someone asked. How do they handle these? Beck said that they need to be evaluated by looking at distortions on the surface, such as "nobody respects me, my family hates me", etc, and then "work your way down" to the underlying core beliefs such as "I am worthless" and then, as Ellis does also, ask "What is the evidence?" for that core belief. Ellis said "I *might* do that, but I might say 'What is the underlying belief?' [right away], and go right to 'Why MUST you be loved and approved of by everybody?' I try to show, in the whole session, there's always a *reason* for the belief."

ELLIS IN A NUTSHELL:
In terms of dysfunctional beliefs, Ellis concluded,
"Everything boils down to 3 things":

I must do well

You must treat me well

The world must be easy.

Dr. Farley asked Dr. Beck, who had never before been face to face with Ellis like this, if he had any question he'd like to pose to his fellow luminary.
Beck reflected and then said, to Ellis:
"Everybody believes they're right. Why should we believe *you*?" Not missing a beat, Ellis replied, "I believe the probability exists that I'm wrong and they're right... but it's only a low degree of probability."

Finally, another question from the audience asked what they thought of recent research suggesting that theoretical orientation doesn't seem to matter in terms of predicting outcome...
Beck noted the early findings (by Rogers and others) that warmth and empathy seem to play a key role. Ellis noted that "lots of horses--- is in there, too. If Jerome Frank was right, the psychotherapist has a philosophy of meaning he sells the patient..."

Whatever the differences in philosophy and belief, it was quite an exciting presentation in which these 2 masters of cognitive therapy seemed to be quite "in sync" with each other in terms of identifying how belief systems underlie behavior, and how the Shoulds and Musts have underlying roots which can and should be changed through cognitive strategies which are convincingly presented as necessary and accepted by patients, with some anxiety at first, and then with lasting and productive changes in beliefs and consequent behavior.